The role of integrated medical and prescription drug plans in addressing racial and ethnic disparities in medication adherence

Medication nonadherence in the United States contributes to 125,000 deaths and 10% of hospitalizations annually. The pain of preventable deaths and the personal costs of nonadherence are borne disproportionately by Black, Latino, and other minority groups because nonadherence is higher in these groups due to a variety of factors. These factors include socioeconomic challenges, issues with prescription affordability and convenience of filling and refilling them, lack of access to pharmacies and primary care services, difficulty taking advantage of patient engagement opportunities, health literacy limitations, and lack of trust due to historical and structural discrimination outside of and within the medical system. Solutions to address the drivers of lower medication adherence, specifically in minority populations, are needed to improve population outcomes and reduce inequities. While various solutions have shown some traction, these solutions have tended to be challenging to scale for wider impact. We propose that integrated medical and pharmacy plans are well positioned to address racial and ethnic health disparities related to medication adherence.

In the United States, approximately 125,000 deaths and 10% of hospitalizations annually are attributable to poor medication adherence. 1 In 2012 alone, nonadherence was estimated to cost the health care system between $100 billion and $300 billion. 1

SUMMARY
Medication nonadherence in the United States contributes to 125,000 deaths and 10% of hospitalizations annually. The pain of preventable deaths and the personal costs of nonadherence are borne disproportionately by Black, Latino, and other minority groups because nonadherence is higher in these groups due to a variety of factors. These factors include socioeconomic challenges, issues with prescription affordability and convenience of filling and refilling them, lack of access to pharmacies and primary care services, difficulty taking advantage of patient engagement opportunities, health literacy limitations, and lack of trust due to historical and structural discrimination outside of and within the medical system. Solutions to address the drivers of lower medication adherence, specifically in minority populations, are needed to improve population outcomes and reduce inequities. While various solutions have shown some traction, these solutions have tended to be challenging to scale for wider impact. We propose that integrated medical and pharmacy plans are well positioned to address racial and ethnic health disparities related to medication adherence.

Plain language summary
Patients not taking their prescribed prescription medications can result in unnecessary sickness and death. This cost and preventable progression of disease disproportionately affects minorities. The underlying reasons for this are complex, and solutions that have shown promise have had challenges scaling. We propose that integrated (ie, combined) medical and drug plans, due to their incentive structures, are well positioned to be one scalable solution to this health equity problem.

Implications for managed care pharmacy
This Viewpoints article suggests that integrating medical plans with managed care pharmacy plans is one scalable solution to addressing health disparities related to medication nonadherence.
health status, out-of-pocket costs, and refill convenience. 11 Closing gaps in how prescriptions are accessed and used by different patient populations should be part of the solution to addressing well-documented health disparities. [13][14][15][16][17] In this Viewpoints article, we discuss the structural, social, and economic drivers of racial and ethnic disparities in medication adherence. Given the lack of explanatory power of observed variables as drivers of nonadherence, 18 and the paucity of conclusive evidence regarding optimal policy approaches to address these disparities, we introduce the concept of integrated medical and prescription drug plans to better meet the health care needs of at-risk, marginalized, and low-resourced populations. We believe integrated plans could contribute to meaningful progress on closing the medication adherence gap that contributes to health inequities in the United States. Employing these policies may offer innovative ways to bring value to health care while simultaneously providing effective supports to enhance prescription drug adherence.

Drivers of Racial and Ethnic Disparities in Medication Adherence
Decades of research point to several drivers of racial and ethnic disparities in medication adherence in the United States, such as socioeconomic factors, challenges related to prescription affordability and convenience, lack of access to pharmacies and primary care services, difficulty with patient engagement and lack of trust due to historical and structural discrimination, and limitations in health literacy. [19][20][21][22][23][24][25][26][27] AFFORDABILITY Prescription drug affordability is critical to accessibility and subsequent adherence. 28-30 Unaffordability and inability to pay contributes to nonadherence and poor outcomes. 6,31 Minority communities have higher rates of poverty, food insecurity, and housing instability, which makes these groups among the hardest hit by rising drug prices and more likely to be affected by cost-related nonadherence. [19][20][21][32][33][34][35][36][37][38][39][40][41] Controlling for demographics, health status, out-ofpocket costs, convenience of refilling prescriptions, and socioeconomic status attenuates, but does not eliminate, the association between race and ethnicity and adherence. 11 Therefore, addressing affordability is an important component for reducing adherence disparities associated with race, but not the only step needed to close the medication adherence gap between White populations and other racial and ethnic groups.

ACCESS
Affordability does not ensure access. Although controlling for out-of-pocket costs and socioeconomic status attenuates the effect of race on adherence, it does not ameliorate it completely. 11 Significant structural and systematic barriers to access remain, such as lack of access to primary care services and retail pharmacies.
A trusted physician-patient relationship, care continuity, and integrated care-all of which may be improved by regular primary care access-are associated with better medication adherence. 24,42-45 However, Black individuals are more likely to live in communities without adequate primary care access. 22 This lack of access to a regular primary care provider disproportionately and directly contributes to medication nonadherence among minority individuals. 24 Lack of retail pharmacy access is a significant contributor to nonadherence, as well. Many lower-income and minority residents face "pharmacy deserts," loosely defined as geographic areas lacking access to a nearby pharmacy and where pharmacy services are scarce or difficult to obtain. 23,46-48 Pharmacy deserts disproportionately exist in segregated Black communities, and this disparity has widened over time, 23 with documented impacts on medication adherence. 49

ENGAGEMENT AND TRUST
Structural racism and individual-level discrimination in health care contribute significantly to health disparities by driving mistrust of the medical system among Black, Latino, and other minority individuals. [50][51][52][53] Many Black patients have been exposed to breaches of trust by the US health system in our history, including the Tuskegee study and origination of the HeLa cell line, and have expressed being treated unfairly by medical staff. [54][55][56] More broadly, social inequity adds to the mistrust of a historically White, mainstream, medical establishment among minority populations. 27 Some data demonstrate that the "distrust gap" between Black and White patients has improved in recent years. 57 Yet, other research paints a less-promising picture, with significantly more medical and clinician mistrust among minorities and reports of less compassionate and more hurried careexperiences and beliefs that correlate strongly with poorer prescription adherence. [58][59][60][61][62] Distrust drives patterns of lower health care utilization and poorer chronic condition management among Black adults. 27, 63 Health literacy is an individual's ability to understand and use information and services intended to inform health-related decisions and actions. 64 Limited health literacy is a significant driver of health disparities and is directly related to nonadherence. A meta-analysis found health literacy to be positively associated with adherence Closely monitoring medication adherence in specific cohorts and conducting targeted outreach to identify lowcost or no-cost prescription medications, especially when done in conjunction with other interventions, may reduce disparities in access for vulnerable populations.

IMPROVING ACCESS
Mail-order pharmacy is a medication delivery service intended to increase drug access and patient convenience, and these services have been associated with improved overall adherence rates compared with adherence rates for patients using retail pharmacies. 76,77 Adherence rates for statins, anticoagulants, antihypertensive drugs, diabetes medications, and many other drug classes have been reported to be higher for patients using mail-order pharmacy. [78][79][80][81] Coordinating mail-order pharmacy programs with synchronization of medication refills may provide additional benefit, particularly for patients with poorer baseline adherence. 82,83 While mail-order pharmacy services have resulted in improved medication adherence, previous research has demonstrated that White patients were more likely than minority patients to use mail-order pharmacy services. 11, 84 Further research is warranted to explore the racial and ethnic disparities associated with mail-order pharmacy use, althoughy previous explorations have uncovered lack of knowledge around mail-order pharmacy, unstable housing situations, and inconsistent access to mail delivery as barriers to mail-order use. 85 There is an urgent need to address underlying systemic disparities and conduct targeted outreach to address the specific needs of individual populations. Interventions that include mechanisms for preferred channels of communication and culturally relevant outreach should be developed and tested. 86

IMPROVING ENGAGEMENT, EDUCATION, AND TRUST
Building trust with minority populations is critical to engagement and education, and this, in turn, may support better prescription adherence among minority groups and better health outcomes. 87,88 Public policy should focus on investing in a more ethnically diverse and representative provider workforce because these efforts can lead to increased access in underserved areas, improved cultural competence and communication, and higher patient trust and satisfaction, which ultimately facilitates better health outcomes. 89,90 Allowing for more patients to receive care from a racially concordant doctor may improve medication adherence, as well. An intervention in Oakland, California, found that pairing Black male patients with Black male physicians may reduce the Black-White cardiovascular mortality gap by 19%. 91 for medication treatment of acute and chronic disease. 65 Both African-American race and lower health literacy have been associated with decreased levels of diabetes medication adherence. 66 Data suggest that up to half of older Black Americans have limited health literacy, 67 and a systematic review identified health literacy as one of the more important mediators of race-related medication adherence disparities. 68 It should be noted that disparities in health literacy are the result of structural forces such as lower socioeconomic status, lack of access to quality educational resources, and racism.
Taken together, these differences in trust in the health care system [50][51][52][53] and disparities in health literacy 69,70 may contribute to differing beliefs in treatment value and effectiveness. 71 This, in turn, may contribute to race-based adherence disparities.

Approaches to Reduce Disparities in Adherence
Over the past several decades, programs to address the drivers of lower prescription adherence have been studied in diverse populations. Many programs have been deployed on a small scale, and some show promise for reducing racial and ethnic disparities related to adherence and may be scalable. In the following sections, we briefly review some promising approaches.

ADDRESSING AFFORDABILITY
Evidence supports the role of improved affordability as a contributor to better medication adherence. The Post-Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE) trial demonstrated that providing full drug coverage increased medication adherence in White and non-White patient groups, although this approach reduced rates of major vascular events or revascularization only in the non-White group. 72 Among White, Black, or Hispanic respondents who used at least 1 cardiovascular medication, creation of the Part D benefit was associated with a 16-percentage point decrease in the White-Hispanic disparity in 12-month medication adherence. 73 A reduction in prescription adherence was not observed between the White and Black cohorts in this study. This suggests that eliminating copays and cost sharing alone may not be enough to support improved adherence among Black patients, although a combination of approaches may be effective. For example, integrating drug affordability programs with medication regimen simplification, education, reminders, and positive financial incentives may improve prescription adherence rates among Black patients. 74,75 Because the cost of nonadherence often manifests in adverse clinical outcomes and downstream medical expenditures, 98 investing in strategies to improve adherence not only creates improved health outcomes for the individual, it also avoids the occurrence of additional health care expenditures by the beneficiary and the payer. 98 While siloed pharmacy plans may have data on prescription medication adherence, they have little incentive to focus on adherence precisely because the pharmacy plan is not incentivized to take these steps; the value of improved adherence would be captured by the medical plan in cost savings, but not by the pharmacy plan. Evidence from our experience suggests that members in integrated commercial and Medicare Advantage plans have lower costs, fewer emergency visits, fewer inpatient admissions, and better medication adherence rates compared with plans that are not integrated. 99,100,101 Further research is needed to better understand adherence outcomes between integrated and nonintegrated plans.
Integrated medical and prescription plans are also positioned to better coordinate medical and pharmacy benefits and to integrate data and interventions across medical and pharmacy programs to more holistically address medication nonadherence. This level of integration provides a mechanism to directly focus on the adherence component of health disparities and connect patients to existing pharmacy initiatives, such as medication therapy management (MTM) programs. MTM uses medical and pharmacy data to support appropriate medication use through identification of suboptimal prescription drug adherence and drug-drug interactions. For example, many integrated medical and pharmacy plans have therapeutic interchange programs that identify opportunities for beneficiaries to reduce out-of-pocket costs by switching to lower-cost prescription drugs.
Increased incentives to coordinate care allow chronic disease management programs, patient and provider education and engagement, prescription home delivery services, and medication synchronization services to be delivered simultaneously to the patient. With newer and more sophisticated predictive analytics, integrated datasets might also allow for better prediction of nonadherence, better anticipation of the most impactful interventions, and an improved efficacy and efficiency of outreach methods and channels for behavior change.
Finally, leveraging existing community and provider partnerships to build trust and engagement is another lever that integrated plans are uniquely positioned to use to address disparities in adherence. Medical plans are already working with community organizations and health care providers as part of their core business functions. But A 2017 review identified practical approaches to addressing medication adherence with the potential to attenuate disparities, including patient engagement strategies, pharmacist-led engagement, and cognitive-based behavioral interventions. 92 Similarly, a systematic review found that interventions focused on engagement and education had a greater effect on adherence in lower-income and racial-ethnic minority patient groups than White and higher-income populations. 65 One particularly promising approach to engagement and activation-motivational interviewing-has been shown to close gaps in adherence. 93,94 At Humana, a national health and wellness organization, a motivational interviewing intervention narrowed racial disparities in medication adherence, increasing proportion of days covered among Black patients by 3%, compared with 1% for White patients (unpublished data, Humana Inc., Integrated Health Services, September 2021).
Community-based approaches for improving trust in the medical system and access to high-quality information in a culturally relevant space, coupled with medication delivery services, may offer particular value for minority groups because they leverage social institutions that have preexisting social trust as an entrée into engagement and education. For example, among Black male barbershop patrons with uncontrolled hypertension, health promotion by barbers, which may improve trust, coupled with medication management delivered in barbershops by pharmacists measurably improves blood pressure control. 95,96 The medication management component, when delivered in a culturally relevant context, may improve adherence through enhanced health literacy. 66,67,69,70 Scalability of such programs can be a limiting factor toward greater impact.

A Unique Opportunity for Integrated Medical and Prescription Drug Plans
Despite recognizing the high prevalence of racial and ethnic disparities in medication adherence and how these disparities amplify health inequities, 11,18,26,59,97 meaningful progress in impacting this challenge has been slow. 11 A coordinated effort among stakeholders across the health care continuum is needed to more rapidly develop and implement promising approaches to reduce disparities in medication adherence. By better aligning financial incentives across medical and pharmacy spending, and coordinating medical and pharmacy benefits and programs, integrated medical and prescription drug plans may be well suited to address the structural limitations that have prevented progress in reducing disparities in medication adherence. better coordination of medical and pharmacy benefits and care management activities. Further research is needed to better clarify the impact of integrated medical and pharmacy plans and related programs in reducing racial and ethnic disparities in prescription adherence.

DISCLOSURES
This study was not supported by any funding sources other than employment of all authors by Humana Inc. Humana products and programs are referred to in this article. the inclusion of pharmaceutical plans allows plans to use these existing partnerships as a foundation on which to build medication-specific efforts and programs.
These partnerships can improve communication, build trust, improve integrated care, increase referrals, and enhance access to community health programs that can help meet the medical, social, and economic needs of each patient. This can be especially impactful when partnerships are developed with trusted community organizations, particularly those programs that have close ties within the communities they serve. This provides an opportunity to lend those community groups' social trust and to translate that into trust in the healthcare plan and provider. Examples of this includes Humana's partnership with Black churches and faith-based organizations to address medically adjacent social needs, 102 such as food insecurity, transportation needs, and social isolation, as well as our recent COVID vaccine equity efforts. The challenge in this is that trust is difficult to scale quickly.

Conclusions
Disparities in medication adherence are a clear and persistent source of structural inequality in our health care system, driving downstream inequities in the health and well-being of minority populations. Progress to reduce disparities in medication adherence has been slow. 11 A combination of misaligned incentives, fragmented health care delivery, poor coordination among pharmacy and medical management programs, and a failure to fully leverage community partnerships have all constrained progress. Integrated medical and pharmacy plans are structurally well positioned to address these limitations through aligned incentives and